What Is CDSS?

In today’s society, the accuracy of health information, the availability of health records, and the professional resources in which one live are vital in decision making for health conditions. Meaningful Use (MU) is a program developed by CMS Medicare and Medicaid that awards, incentives in the health care industry in which the certified electronic health records (EHRs) are used to improve patient care (Practice Fusion, 2016). These incentives are for professionals that care for about 30% of their adult patient volume or 20% of their children’s volume for Medicare and Medicaid patients (CMS, 2016). In addition, adjusting from paper charts to electronic charts of patient’s information is beneficial for MU. Furthermore, the American

In the medical field there have been a lot of technological advances and making health records electronic is one of them. The days of having a paper health record are almost obsolete. An electronic health record keeps a patient’s medical information and history on a computer which is accessible to more people in less time. I will explain how the continuity, communication, coordination and accountability of the electronic health record can help the medical office. I will explain what can be included in the electronic health record. As an advocate of the electronic health record I will also explain some disadvantages to the electronic system.

In regards to technology and how its influences healthcare today we see the use of EHRs, which allows for a high capacity healthcare environment by condensing patient information into an easily accessible form for all healthcare professionals. “EHRs allow us to collect meaningful data to determine the efficacy in which our units are functioning” (Biddle & Milstead 2016, p.12). This technology can help manage the high capacity hospital environment while not compromising quality. This

2008). Another system focused on patient scheduling in a rehabilitation setting (Ozbolt, J.G., Saba, V.K. 2008). Nurses at a California hosptial assisted in developing the first comprehensive hospital information system and helped integrat the system for nursing care planning, documentation, and feedback (Ozbolt, J.G., Saba, V.K. 2008). They developed the standard care plans that are used throughout the world today (Ozbolt, J.G., Saba, V.K. 2008). Another big achievement of this decade was the introduction of the first commercial electronic medical record (Thede, L. 2012). This new system was patient-oriented and was implemented throughout the hospital (Thede, L. 2012).

Electronic Health Record (EHR) compliance is expected to achieve better clinical outcomes, improved population health outcomes, increased transparency and efficiency, empowerment of individuals, and more robust data for research on health systems (Health IT). The determination of this paper aims to evaluate the flow of information as it travels with patients as they enter the emergency room, up to and including a skilled nursing facility stay. Over the last decade an emphasis has been placed on transitioning from paper based documentation to electronic based computerized systems. The centers for Medicaid and Medicare place such high emphasis on this transition that monetary incentive including higher reimbursement rates

Health care providers as well as nurses must keep track of all pertinent patient information and failure to do so leads to detrimental effect on the patient's life. CIS clinical information systems are "large, computerized database management systems that support several types of activities that include physician order entry, result retrieval, documentation and decision support". CIS is intended to replace medical records department of a hospital or any other medical institution. Physicians and clinicians can safely and quickly access information, order medication and treatments and implement appropriate care. CIS will hopefully improve productivity, increase quality care and reduce costs across the organization.

Within the Electronic Health Record program, the nurse has access to evidence-based practice tools that can assist the nurse in making decisions regarding the patients plan of care (Linder, J., Bates, D., Middleton, B., & Stanfford, R., 2007). The most important feature of the Electronic Health Record is the ability to instantly provide real-time patient-centered data to all authorized providers (HIT, 2013). The Electronic Health Record is real-time, providing nurses with the most up to the moment patient information the significance of this feature can be explained in the following example. For example, if a patient is in surgery, the patient's health record is available to the circulating nurse in the Operating Room, the Post Anesthesia Care Unit nurse and can be shared with the unit staff nurse the patient will be transferred to after recovering in the Post Anesthesia Care Unit. This is of particular importance because having access to the patient's chart, allows the nurses at each phase on the patient's care the ability to prepare supplies, gather necessary equipment and arrange for supplementary staff. Evidence-based practice suggests appropriate planning is a key factor in promoting positive, cost efficient patient outcomes (Anderson, 2012). In the profession of nursing when time is of the essence, and time loss can mean loss of a life, this is a feature that is very

A lengthy list of EHR benefits supports the evolution from paper to electronic medical record keeping. One such benefit, the significant reduction of needed storage space. Bulky paper charts require a lot of space and misplaced charts waste time and effort to locate. Since EHR data remains on the computer, medical practices no longer require secure on-site storage, and electronic files eliminate misplacing files. Another benefit to data remaining on the computer rather than a medical chart, electronic records allow immediate access from several locations. EHRs provide emergency room personnel access to allergies and other pertinent information of unconscious patients. The on-call physician accesses patient information from their home computer, rather than driving to the medical

The electronic medical records has helped improved overall patient care . Allowing simple real-time charting for nurses has made charting more accurate and efficient.It allows for insurance to be billing to more efficient. Doctors can view a whole life time of health care information in one spot and review results quickly.

The handwritten documentation has been the usual way of recording medical data since the nineteenth century. However, the fast development of computer technology has led to the advancement and use of electronic medical records (EMRs) throughout the past several decades (Jerant & Hill, 2000). The evolution from a paper to an electronic setting can be somewhat straightforward. The two leading reasons why most facilities chooses to convert to EMRs is patient care and safety. Health-care Information and Management Systems Society (HIMSS) presented its EMR adoption model in 2005 and now tracks the implementation growth of more than 5000 U.S hospitals (Traynor, 2011).

Besides the disadvantages of (EMR)’s the advantages pose great benefits to patient care and efficiency. The greater use of electronic medical records or health records can reduce wait times, of seeing doctors or waiting for test results. All staff would need to cohesively work out the technical challenges and software data. With sophisticated IT

There are many different healthcare settings, which Electronic Health Records (EHR) have been implemented. One may think EHR’s are the same for all settings; however, based on the needs and application to each area, there are similarities and differences. This paper will delve into the Perioperative setting and Ambulatory setting in primary care. Information provided will highlight the value of Electronic Health Information (EHI), its impact at the warehouse and regional level as it improves patient care among the respective practitioners in these settings and its impact to Public Health Information Networks (PHIN) and National Health Information Networks (NHIN).

Electronic Nursing documentation increased health care quality for the patient. This can be seen because electronic documentation is done at each interaction that takes place within the patient’s room. This is known as point of care documentation (Duffy,Kharasch, Hongyan, 2010). Another benefit to documenting at the bedside is nurses have to physical see the patient in order to complete documentation, therefore increase

The shift to evidence-based practices within the nursing field is to improve quality improvements and to overall protect the patient. The use of the electronic health record in nursing informatics go beyond just inputting data. The electronic health record can be used to increase reporting standards, results management, decision support, and communication. The use of electronic health record is helpful for nurses to provide education to the patients. It also creates the collection of data that can be used for preventing disease with the patient consent. Certain public health causes must be reported and having an electronic paper trail protects the providers and nurses in the end. On a global scale, the use of electronic health record is endless.

In today’s medical field technology plays a big role when it comes to patient care. Technology is huge when it comes to giving the patient the best type of quality care when they are in the hospital. In the old days people would just write it down on a sheet of paper and record it by hand, which caused mistakes. Now with the Electronic Health Record those mistakes are drastically declining. Statistics have shown that using the Electronic Health Record has lowered Nursing mistakes as well as improved patient care. Our society has progressed through the years and has been introduced with the Electronic Health Record which has drastically improved our health care system. The Electronic Health Record provides great communication between